Shared learning database

Type and Title of Submission


Process for dissemination of NICE guidance (and other national guidance) and assurance mechanism


This submission describes SRFTs process for dissemination of NICE guidance. The process and assurance mechanism ensures that the Trust has comprehensive documentation of the applicability of NICE guidance to the services it delivers. It explains the processes used to ensure clinical audit evidence of compliance is forthcoming.



Does the submission relate to the general implementation of all NICE guidance?


Does the submission relate to the implementation of a specific piece of NICE guidance?


Full title of NICE guidance:


Category(s) that most closely reflects the nature of the submission:

Implementation policy
Terms of reference for implementation team

Is the submission industry-sponsored in any way?


Description of submission


At the beginning of 2008 the Trust realised that its system of disseminating NICE guidance and the methods used for ensuring compliance and providing Board assurance required revision. There were gaps in the assurance process. The aim was to streamline the process, develop a group, the Clinical Guidance Steering Group, with overarching responsibility to review all issued national guidance, delegate to named clinical leads and seek audit evidence of compliance. It was set up to ensure a functioning management process that would enable the Trust to have comprehensive records of applicable guidance, that audit projects were planned to provide Board assurance of compliance and that clinicians had support with implementation of guidance.


1) To ensure timely dissemination of new guidance 2) To develop and maintain an accurate recording system 3) To ensure clinical audit evidence of compliance


The original system was that NICE TAs and CGs were assessed and discussed at Medicines Management Group and assigned a clinical lead where appropriate. Documentation of clinical leads, applicability of guidance, any correspondence was kept on an Excel spreadsheet and updated as appropriate. NICE IPGs were assessed at a different group led by a surgeon. There was no documentation available. The Trust required a new, more effective mechanism with thorough recording processes and senior Trust personnel with responsibility for ensuring the process functioned well. A new policy was written and approved by Clinical Effectiveness Committee. This policy incorporates all national guidance (NICE, NSFs, NCEPOD etc). The Clinical Audit Managers role was extended to include National Guidance Management. On formation of the Clinical Guidelines Steering Group a Trust-wide gap analysis was performed. This aimed to identify gaps and secure evidence of assurance for all national guidance back to 2003.


The gap analysis highlighted concerns that had arisen. The new system (now 18 months on) has shown that:- 1) The new process ensures consideration and timely dissemination where appropriate to key Trust personnel 2)The Trust has a comprehensive recording system for all national guidance and its applicability to the services provided 3)Clinical audit evidence has been forthcoming and specialties are planning audits against NICE guidance into their forward plans 4)Barriers are mainly in the form of securing audit evidence

Results and evaluation

1) Spreadsheet of NICE guidance updated monthly as guidance is issued 2) A record of all communication regarding dissemination of NICE guidance is updated as appropriate 3)Areas of concern are highlighted to the Clinical Guidance Steering Group and Clinical Effectiveness Committee 4)Clinical audits are identified and planned providing specialty forward plans 5)All guidance back to 2003 has been issued to clinical leads with a request to review the guidance, plan audits 6)Bi-annual reports from the Clinical Guidance Steering Group are presented to Clinical Effectiveness Committee and the PCT

Key learning points

1) A dedicated national guidance manager is essential for the process to function 2)Support from senior Trust personnel such as the Medical Director is essential 3)Excellent communication is vital for success 4)Imparting the message to clinicians that this is not just a tick-box exercise is essential to obtain co-operation 5)Provision of adequate support services for clinicians eg Clinical Audit Team is essential 6)Ensure that discussion, evaluation and monitoring of adherence to national guidelines is on all specialty/directorate agendas 7)Streamline systems and processes as much as possible so as to minimise demand put on already busy clinicians 8)Maintain a sense of humour!

View the supporting material

Contact Details

Name:Mrs Karen Powell
Job Title:Clinical Audit & National Guidance Manager
Organisation:Salford Royal NHS Foundation Trust
Address:Stott Lane
County:Greater Manchester
Postcode:M6 8HD
Phone:0161 206 5113


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This page was last updated: 30 September 2009

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Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.